3/4/2010 1 Soft Tissue Injuries Physical Medicine & Rehabilitation Lecture Series 6/6 Define the following • Sprain • Strain • Bursitis • Tendinitis • Rupture • Fibromyositis • Fibrositis • Myosistis Sprain • An injury involving the stretching or tearing of a ligament (tissue that connects bone to bone) or a joint capsule (connective tissue secreting synovial fluid), which help provide joint stability. Sprain • A severely damaged ligament or joint capsule can cause instability in a joint. Sprain • Symptoms may include –Pain –Inflammation –inability to move a limb (arm, leg, foot) • Sprains occur when a joint is forced beyond its normal range of motion, such as turning or rolling your ankle. Types of ligament injury • Partial –a. part of the ligament may be torn while the rest are undamaged –b. & c. part of the ligament attachment may have been torn away from its insertion with or without a bone fragment
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• Are injuries that involve the stretching or tearing
of a musculo-tendinous (muscle and
tendon) structure.• An acute (instant or recent) strain of the
musculo-tendinous structure occurs at the junction where the muscle is becoming atendon. These strains take place when a muscleis stretched and suddenly contracts, as withrunning or jumping.
Strain
• This type of injury is frequently seen inrunners who strain their hamstrings. Manytimes the injury will occur suddenly whilethe runner is in full stride.
Strain
• Symptoms for an acute muscle strain
– Pain
– muscle spasm
– loss of strength
– limited range of motion
Epidemiology
• 10-30% of all sport injuries
• Muscles may be damaged by direct trauma(impact) or by indirect trauma (overloading)
• Ruptures – can be partial or total and may besubdivided into distraction and compressionruptures
• Hematomas – either inter or intramuscular types
Bursitis
• Bursa – small fluid filled sacs whose
function is to distribute stress and reducefriction
• Conditions which affect bursae areinflammatory (bursitis) or caused byimpact with subsequent bleeding
(haemobursa)
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• If the sheath of tissue that surrounds the tendonbecomes scarred and narrowed, it may cause
the tendon to lock in one position, such as in thecondition called trigger finger.
• The pain of tendinitis is usually worse withactivities that use the muscle that is attached tothe involved tendon.
Treatment
• The goals of tendinitis treatment areto relieve your pain and reduceinflammation.
• Often, simple home treatment —which includes rest, ice and over-the-counter pain relievers — is all that
you need.
Treatment
– Injected steroids.
– Strengthening exercises. People with tendinitisand tendonosis may also benefit from aprogram of specific exercise designed tostrengthen the force-absorbing capability of the muscle-tendon unit.
Treatment
– Surgery. When a tendon is torn, you mayneed a reconstructive operation to cleaninflamed tissue out of the tendon sheath or torelieve pressure on the tendon by removing
bone
Fibromyositis
• Fibromyalgia is a chronic disorder
characterized by pain throughout much of the body. The pain may begin gradually orhave a sudden onset.
• The exact cause of this disorder isunknown.
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· Painful menstruation.· Numbness and tingling in the extremities.· Dizziness or light headedness.· Skin and chemical sensitivities.
Symptoms
• Muscle spasms
• Fatigue
• Muscle tissue stiffness
• Non- restorative (unrefreshing) sleep.
Symptoms
• Pain: The most prominent symptom of fibromyalgia ispain. Unlike arthritis, the discomfort is not in the jointsbut in the muscles and ligaments. The tenderness isworse in the mornings and has been described as flulike,burning, throbbing, aching, or stabbing.
• Fatigue: Another frequent complaint associated withfibromyalgia is fatigue. The severity of the fatigue canrange from mild to incapacitating. No amount of sleep atnight or rest during the day is helpful.
Symptoms
• Fibrofog: Another common symptom is a mentalhaziness some people call fibrofog. This refers to theinability to concentrate, memory loss, and depressionthat occurs with fibromyalgia.
• Other symptoms associated with fibromyalgia areheadaches, nervousness, numbness, dizziness, andintestinal disturbances.
Diagnosis
• According to the American College of Rheumatology, before the diagnosis of fibromyalgia can be made, the muscle pain mustbe present for longer than 3 months.
• Pain must occur at specific sites on the bodycalled tender points. There are 18 of thesesensitive spots. Most are located on the neck and back.
Treatment
• Although there is no cure for fibromyalgia, hometreatment can relieve some of the symptoms.
• The most important therapy for muscle pain isregular, low-impact exercise. Keeping musclesconditioned and healthy by exercising 3 times aweek decreases the amount of discomfort.
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• Myositis can take several forms, usually developsslowly over time and can range in severity frommild to debilitating or worse.
Symptoms
• Weakness and pain in the muscles of the hipsand shoulders is often a first sign of myositis.
• Myositis can affect the muscles in the front of the neck and throat, making it hard to speak orswallow (dysphagia).
• When it affects the lungs or chest muscles, youmay have trouble breathing.
Diagnosis
• Physical exam will probably include one ormore blood tests to look forautoantibodies and muscle enzymes suchas creatine kinase (CK).
• Other specialized tests such as anelectromyogram (EMG), which measuresthe electrical pattern of the muscles.
Forms of myositis
• Polymyositis (PM)
• Dermatomyositis (DM)
• Inclusion Body Myositis (IBM)
• Juvenile Myositis (JM)
Polymyositis (PM)
• PM inflames and weakens muscles inmany parts of the body, especially thoseclosest to the trunk (proximal). Dysphagiais common, as is fatigue and pain in the joints and muscles.
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• DM inflammation damages both musclefibers and skin. Like PM, you develop
muscle weakness, pain and fatigue. Inaddition, you have a distinctive patchy,reddish rash on the eyelids, cheeks, bridgeof the nose, back or upper chest, elbows,knees and knuckles. In some cases, youmay develop hardened bumps under theskin.
Inclusion Body Myositis (IBM)
• Symptoms of IBM typically begin after age 50with very gradual weakening of muscles
throughout the body. You may developdysphagia, weak wrists or fingers and atrophy of the forearms and/or thigh muscles. Unlike otherforms of myositis, IBM occurs more often in menthan in women and, unfortunately, there are noeffective treatments known for IBM.
Juvenile Myositis (JM)
• Although some children develop juvenileforms of PM and IBM, children usually get juvenile DM with symptoms of muscleweakness, skin rash and dysphagia.
Treatment
• Medications: Corticosteroids (i.e., prednisone) andother drugs that suppress the immune system(immunosuppresants) may slow down the attack onhealthy tissue and improve skin rash.
• Exercise: After drug treatment takes effect, a programof regular stretching exercises prescribed by your doctorcan help maintain range of motion in weakened armsand legs. Physical therapy may also help preventpermanent muscle shortening.
• Rest: Getting enough rest is an important component of
managing myositis.
Wound Healing
• The past decade has seen an explosive growth
of wound healing research that promises to
facilitate clinical wound repair.
TISSUE INJURY AND
TYPES OF HEALING
• Primary intention
• Secondary intention
• Third intention
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– (1) alpha granules contain growth factors such as platelet-
derived growth factor (PDGF), transforming growth factor-beta (TGF-b), and insulin-like growth factor-1 (IGF-1), aswell as adhesive glycoproteins such as fibronectin,fibrinogen, thrombospondin, and von Willebrand's factor;
– (2) dense bodies store vasoactive amines such asserotonin, which increase microvascular permeability; and
– (3) lysosomes contain hydrolases and proteases.
Inflammation
• Monocytes infiltrate later at the wound site and
differentiate into macrophages that are crucial in theorchestration of tissue repair.
• Most wound macrophages are converted monocytesthat are recruited from the circulation, but some aretissue macrophages that can proliferate locally.
• Macrophages continue to consume tissue andbacterial debris but, more important, secrete aplethora of growth factors
Granulation
• Granulation tissue is characterized by its
beefy-red appearance, a consequence of
endothelial cell division and migration to form
a rich bed of new capillary networks
(angiogenesis) at the wound site.
• Granulation is most prominent in wounds
healing by second intention.
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• Is released from platelet alpha granules immediatelyafter injury. PDGF attracts neutrophils, macrophages,and fibroblasts to the wound and serves as apowerful mitogen.
• Macrophages, endothelial cells, and fibroblasts alsosynthesize and secrete PDGF.
• PDGF stimulates fibroblasts to synthesize newextracellular matrix, predominantly noncollagenouscomponents such as GAGs and adhesion proteins.
PDGF
• PDGF also increases the amount of fibroblast-
secreted collagenase, indicating a role for this
cytokine in tissue remodeling.
aFGF and bFGF
• Angiogenesis is stimulated by acidic and basic
fibroblast growth factors
• Angiogenesis is the formation of new blood
vessels by directed endothelial cell migration
and growth. This widespread process occurs in
development, cancer, and wound healing.
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the extracellular matrix that allow cells todetach and migrate.
• The matrix provides the scaffolding for cellattachment and migration through variousglycoprotein components
Glycoprotein Components
• fibronectin
• tenascin
• laminin
• fibrinogen
• thrombospondin
• vitronectin
Integrins
• Cell-surface adhesion receptors
• Integrins provide a bond among a cell'scytoskeleton, its surrounding extracellularmatrix, and adjacent cells.
• Cell motility direction may be determined bythe relative integrin-ligand binding affinities of the various adhesion glycoproteins bound to aparticular cell.
Fibronectin
• Fibronectins are prominent matrix molecules
involved in wound contraction, cell migration,
collagen matrix deposition, and re-epithelialization.
• Fibronectin is one of the first proteins to be laid
down in a wound and forms part of the preliminary
matrix.
• Fibronectin acts as the scaffold for cell migration and
collagen deposition.
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• Fibronectin is produced by fibroblasts, epithelialcells, and macrophages, and it can bind a wide
variety of molecules involved in wound healing,including collagens, actin, fibrin, HA, heparin,fibronectin itself, and cell-surface receptors onfibroblasts.
• Granulation tissue fibroblasts are coated with a layerof fibronectin matrix, and myofibroblasts are coveredwith fibronectin, which forms part of the fibronexusattachment that effects wound contraction.
CLINICAL FACTORS THAT AFFECT
WOUND HEALING
• Nutrition
• Oxygen, Anemia, and Perfusion
• Diabetes Mellitus and Obesity
• Corticosteroids, Chemotherapy, and Radiation
Therapy
• Infection
Nutrition
• Protein depletion impairs wound healing if recent weight loss exceeds 15% to 25% of body weight.
– Vitamin C is necessary for hydroxylation of prolineand lysine residues. Without hydroxyproline,newly synthesized collagen is not transported outof cells. Without hydroxylysine, collagen fibrils arenot cross-linked.
Nutrition
– Vitamin A (retinoic acid) requirements increase
during injury. Severely injured patients requiresupplemental vitamin A to maintain normal serumlevels. Vitamin A also partially reverses theimpaired healing in chronically steroid-treatedpatients.
– Vitamin B 6 (pyridoxine) deficiency impairscollagen cross-linking. Vitamin B 1 (thiamine) andvitamin B 2 (riboflavin) deficiencies causesyndromes associated with poor wound repair.
Nutrition
• Deficiencies of trace metals such as zinc and
copper have been implicated in poor wound
repair, since these divalent cations are
cofactors in many important enzymatic
reactions.
• Zinc deficiency is associated with poor
epithelialization and chronic, nonhealing
wounds.
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• Oxygen is required for successful inflammation,angiogenesis, epithelialization, and matrix
deposition.• Conversely, increased oxygen delivery at the wound
improves healing.
• Anemia in a normovolemic patient is not detrimentalto wound repair as long as the hematocrit is greaterthan 15%, because oxygen content in blood does notaffect wound collagen synthesis
Oxygen, Anemia, and Perfusion
• Tissue perfusion is the ultimate determinant
of wound oxygenation and nutrition.
Diabetes Mellitus and Obesity
• Wound healing is impaired in diabetic patients byunknown mechanisms.
• Healing is enhanced if glucose levels are wellcontrolled.
• Obesity interferes with repair independently of diabetes.
• Obese patients with diabetes have impaired woundhealing regardless of the degree of glucose controland insulin therapy.
Corticosteroids, Chemotherapy, and
Radiation Therapy
• Use of pharmacologic steroids impairs healing,especially when given in the first 3 days afterwounding.
• Steroids reduce wound inflammation,epithelialization, and collagen synthesis.
• Both radiation and chemotherapeutic agents havetheir greatest effects on dividing cells. The division of endothelial cells, fibroblasts, and keratinocytes isimpaired in irradiated tissue, which slows wound
healing
Corticosteroids, Chemotherapy, and
Radiation Therapy
• Irradiated tissue usually has some degree of
residual endothelial cell injury and
endarteritis, which causes atrophy, fibrosis,
and poor tissue repair.
• Chemotherapeutic agents are not
administered until at least 5 to 7 days
postoperatively to prevent impairment of the
initial healing events.
Infection
• Wound contamination by bacteria causes
clinical wound infection and delays healing if
more than 10 5 organisms per mg. tissue are
present.
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